Family 'ecstatic' after huge fines announced against insurers over autism coverage

by Joe Douglass, On Your Side Investigator

PORTLAND, Ore. —

The state announced huge fines Thursday against four major health insurance companies in Oregon for violations involving mental health coverage.

Two of the cases involve the family of a boy with autism that KATU has talked with for months.

Oregon's Department of Consumer and Business Services (DCBS) is proposing the actions against the companies, which will still get a chance to file appeals.

The family said they're ecstatic, excited and hopeful the proposed actions will help not just them but others facing similar situations as well.

'It's terrifying'

Playful, smiling Cole Cannoy was born in September of 2013.

Cole's parents, Heather Smith-Cannoy and David Cannoy, are clearly head-over-heels in love with their adorable, energetic baby in cellphone videos they shared with KATU.

"He was a healthy boy," said David.

One video shows Cole imitating speech and sounds, which his parents said he can no longer do.

They said the change happened when Cole was about a year-and-a-half old.

"We started to pick up on that and it was pretty alarming," David explained.

"He had lost the ability to speak," said Heather, "and toddlers don't lose the ability to speak when they're healthy."

Cole was diagnosed with autism during the summer of 2015.

"And that was when it became pretty difficult," said David. "It shatters your kind of scenario that you think you're gonna have for your child."

The Cannoys said hope came in the form of three main treatments. The first is applied behavior analysis (ABA), which many experts consider the gold standard of autism therapy.

"It helps him," said David. "It merges him with other kids so that there's some social interaction."

The other primary treatments are speech and occupational therapy.

"The occupational therapy is really amazing for Cole," David said, "because his gross motor skills, his athleticism, his activity are really high and he excels in those areas."

But David and Heather said when they tried to get coverage for treatments in 2015, they ran into trouble.

"As soon as his autism diagnosis happened we started the pre-authorization request for applied behavior analysis," said Heather, "and we were denied quickly with a strange letter that said, 'It's not part of your plan.'"

Cole gets healthcare coverage through Heather, who works as a professor at Lewis and Clark College.

The school along with several other local colleges uses an insurer called Pioneer Educators Health Trust. The trust hires Regence BlueCross BlueShield as a third party administrator.

With the help of an advocate, the Cannoys said they fought for months to get coverage for Cole.

"It's terrifying when you constantly have to interact with insurance companies to insure that your child is getting necessary treatment," said Heather.

She, David and their advocate, Paul Terdal, Oregon chapter policy chair of Autism Speaks, filed consumer complaints with the state.

KATU spoke with them about their struggles last November.

"Under the bulletins from the Insurance Division because of the federal Mental Health Parity Act you cannot impose visit limits on services for mental health conditions," said Terdal.

The state issued those bulletins in 2014.

On Thursday, DCBS and the Oregon Division of Financial Regulation cited the bulletins as they announced proposed orders in the case.

A news release said, in part:

"Oregon’s mental health parity law requires insurers to cover mental health conditions consistent with how they cover physical conditions. The department issued guidance to insurers in 2014 that they cannot categorically deny coverage of mental health treatments, including Applied Behavior Analysis (ABA) therapy, which is used to treat autism.

'Despite our clear guidance to insurance companies on mental health parity, some companies continue to engage in practices that make it difficult for consumers to access treatment,' said Laura Cali Robison, Oregon insurance commissioner and administrator of the DCBS Division of Financial Regulation. “We continue to monitor this issue across the industry and will not hesitate to take strong action if warranted.'

Pioneer Educators Health Trust, which provides health plans to local universities, is fined a proposed $100,000 for several violations, including:

-Applying an annual visitation limit for neurodevelopmental therapy, a mental health treatment, when there was not a similar limit for other medical or surgical benefits -Excluding ABA therapy in its 2015 health benefit plan and issuing the plan without receiving approval from the state -Denying a consumer’s pre-authorization request for ABA therapy and not providing a written response with information about the consumer’s right to appeal. -Denying a claim for ABA therapy with no basis for that denial.

Regence BlueCross BlueShield of Oregon, in its role as third-party administrator for Pioneer Educators Health Trust, is fined a proposed $100,000. In particular, Regence provided incorrect information to Pioneer and at least one consumer about whether it was required to cover ABA therapy."

Jared Ishkanian, a spokesman for Regence, sent KATU the following statement:

"Regence cares deeply about our members, and works diligently to connect them to the care they need. We are disappointed that the department of financial regulation has decided to move forward with this action without giving us the opportunity to respond. We stand by our members with autism and are dedicated to supporting them on their care path."

The proposed actions are called marketplace violations, which the state can issue if insurance companies break rules regarding coverage.

In recent years authorities haven't doled out many of them especially when you consider around 4,000 insurance consumer complaints are filed annually.

In 2016, just five marketplace violations were issued. The year before there were none. And in 2014 there were four.

Lisa Morawski, communications director for DCBS, said more enforcement actions may be on the way.

"One of the reasons the department merged the Insurance Division with the Division of Finance and Corporate Securities last year was to strengthen enforcement," Morawski said via email. "The newly formed Division of Financial Regulation has more resources and anticipates being able to take swifter action in these types of cases."

DCBS announced proposed actions for two other companies as well in separate cases. The news release from the agency says:

"United Healthcare Insurance Company is fined a proposed $110,000 for denying 22 speech therapy claims for children who have been diagnosed with a pervasive developmental disorder (such as autism). Oregon law requires insurers to cover all medical services for a child enrolled in the plan who is younger than 18 years old and who has been diagnosed with a pervasive developmental disorder. Those services include rehabilitation services, such as speech therapy, that are medically necessary and are otherwise covered under the plan.

Kaiser Foundation Health Plan of the Northwest is fined a proposed $250,000 for providing incorrect and misleading information in its member documents about whether it would pay for members’ attorney fees in a lawsuit. Kaiser’s documents stated that members would bear their own attorney fees, but Oregon law requires insurers to honor a court award for attorney fees. This order was the result of a complaint from a consumer who has filed a lawsuit against Kaiser related to mental health parity issues."

"We will continue to talk to the insurers and see if we can get to a place where we both sign a final consent order," said Morawski. "If not, we would issue a notice order, and the insurer would have the opportunity to file an appeal."

Michael G. Foley, a spokesman for Kaiser, sent KATU the following statement:

"Kaiser Permanente is committed to providing effective mental health treatment and supporting the total health of our patients. We are currently evaluating the order from the Oregon Department of Consumer and Business Services related to informing patients about the disposition of attorney’s fees."

"Four years ago, we performed a routine internal audit and identified an isolated processing mistake affecting six of our members. We immediately corrected the error, retrained the employee who made the mistake, and reimbursed our members, with interest, for any medical expenses. UnitedHealthcare continues to cover speech therapy in our insurance plans in Oregon."